Anaesthesia and Intensive Care Journal Latest Issue

The early history of ventilation

C. Ball, RN. Westhorpe — Wed, 01 Feb 2012 00:00:00 GMT

Intra-abdominal hypertension and abdominal compartment syndrome – making progress?

GM. Joynt, JKM. Wai — Wed, 01 Feb 2012 00:00:00 GMT

Risks of anaesthesia and surgery in elderly patients

NM. Gibbs — Wed, 01 Feb 2012 00:00:00 GMT

Benefits and risks of using gelatin solution as a plasma expander for perioperative and critically ill patients: a meta-analysis

MM. Saw, B. Chandler, KM. Ho — Wed, 01 Feb 2012 00:00:00 GMT

This meta-analysis aimed to evaluate the benefits and risks of gelatin solutions compared to other intravenous fluids for patients in perioperative and critical care settings. Of the 66 studies identified from MEDLINE and EMBASE databases, 30 randomised controlled trials involving 2709 patients met the inclusion criteria and were subject to meta-analysis. The risk of mortality (odds ratio 1.03, 95% confidence interval 0.80 to 1.32) and amount of blood loss (weighted-mean-difference 7.56 ml, 95% confidence interval 18.75 to 33.87) were not significantly different between patients who were treated with gelatin solutions and other types of intravenous fluids. When compared to starches, gelatin solutions were associated with a lower risk of acute renal failure (odds ratio 0.43, 95% confidence interval 0.20 to 0.92; P=0.03). When gelatin solutions were compared to isotonic albumin, patients who were treated with gelatin solutions required a small, but significantly greater amount of blood transfusion (weighted-mean-difference 180 ml, 95% confidence interval 8.1 to 353.6; P=0.04). These findings suggest that using gelatin solutions is associated with a lower risk of acute renal failure compared to older starches. Using gelatin as a plasma expander appears to have no significant advantages over crystalloids or isotonic albumin on mortality and may have a slightly higher risk of requiring allogeneic blood transfusion in perioperative and critically ill patients. An adequately powered randomised controlled trial with economic analysis is needed before gelatin solution can be recommended as a routine plasma expander for patients undergoing major surgery or who are critically ill.

The role of regional anaesthesia techniques in the management of acute pain

PJ. Cowlishaw, DM. Scott, MJ. Barrington — Wed, 01 Feb 2012 00:00:00 GMT

Regional anaesthesia and analgesia techniques are used to effectively manage acute pain after a variety of surgeries. With the rapid growth of ultrasound-guided procedures, anaesthetists are re-examining regional anaesthesia and analgesia and their roles in pain management. In this evolving field previous published data may not reflect current practice. Therefore, a narrative review of recent literature was undertaken to establish the current utility and efficacy of regional anaesthesia and analgesia for the management of acute pain following surgery. Only prospective randomised controlled trials published between March 2009 and March 2011 with outcome measures of analgesia efficacy were included. Sixty-five randomised controlled trials were identified involving 4841 patients. Regional techniques for the management of knee (26%), abdominal (26%) and shoulder (14%) surgery were most frequently studied. The review provides further evidence that regional anaesthesia and analgesia can offer excellent analgesia with acceptable side-effects for the management of post surgical pain. In addition, the results of this review support the use of ultrasound guidance when performing regional techniques and continuous catheter techniques to prolong analgesia.

The mitochondrial permeability transition pore and its role in anaesthesia-triggered cellular protection during ischaemia-reperfusion injury

DT. Andrews, C. Royse, AG. Royse — Wed, 01 Feb 2012 00:00:00 GMT

This review summarises the most recent data in support of the role of the mitochondrial permeability transition pore (mPTP) in ischaemia-reperfusion injury, how anaesthetic agents interact with this molecular channel, and the relevance this holds for current anaesthetic practice. Ischaemia results in damage to the electron transport chain of enzymes and sets into play the assembly of a non-specific mega-channel (the mPTP) that transgresses the inner mitochondrial membrane. During reperfusion, uncontrolled opening of the mPTP causes widespread depolarisation of the inner mitochondrial membrane, hydrolysis of ATP, mitochondrial rupture and eventual necrotic cell death. Similarly, transient opening of the mPTP during less substantial ischaemia leads to differential swelling of the intermembrane space compared to the mitochondrial matrix, rupture of the outer mitochondrial membrane and release of pro-apoptotic factors into the cytosol. Recent data suggests that cellular protection from volatile anaesthetic agents follows specific downstream interactions with this molecular channel that are initiated early during anaesthesia. Intravenous anaesthetic agents also prevent the opening of the mPTP during reperfusion. Although by dissimilar mechanisms, both volatiles and propofol promote cell survival by preventing uncontrolled opening of the mPTP after ischaemia. It is now considered that anaesthetic-induced closure of the mPTP is the underlying effector mechanism that is responsible for the cytoprotection previously demonstrated in clinical studies investigating anaesthetic-mediated cardiac and neuroprotection. Manipulation of mPTP function offers a novel means of preventing ischaemic cell injury. Anaesthetic agents occupy a unique niche in the pharmacological armamentarium available for use in preventing cell death following ischaemia-reperfusion injury.

Laptops and smartphones in the operating theatre – how does our knowledge of vigilance, multi-tasking and anaesthetist performance help us in our approach to this new distraction?

CM. Jorm, G. O'Sullivan — Wed, 01 Feb 2012 00:00:00 GMT

There has been no research performed concerning the effects of the use of laptops and smartphones in the operating theatre on anaesthetist performance, yet these devices are now in frequent use. This article explores the implications of this phenomenon. The cognitive and environmental factors that support or detract from vigilance and multi-tasking are explored and core anaesthetic literature on the nature of anaesthetic work and operating theatre distractions is reviewed. Experienced anaesthetists are skilled at multi-tasking while maintaining situational awareness, but there are limits. Noise, interruptions and emotional arousal are detrimental to the cognitive performance of anaesthetists. While limited reading during periods of low task load may not reduce vigilance, computer use introduces text-based activities that are more interactive and potentially more distracting. All anaesthetists need to be mindful of the limits to the human attention span which requires observation and limiting distractions. Trainees have less experience and less ‘attentional’ safety margin, so should avoid adding additional distractions such as discretionary use of laptops or smartphones to their operating theatre work. We provide recommendations for future research on the specific advantages and disadvantages of pervasive computing in the operative theatre.

Incidence, risk factors and outcome associations of intra-abdominal hypertension in critically ill patients

IB. Kim, J. Prowle, I. Baldwin, R. Bellomo — Wed, 01 Feb 2012 00:00:00 GMT

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are significantly associated with morbidity and mortality. We performed a prospective observational study and applied recently published consensus criteria to measure and describe the incidence of IAH and ACS, identify risk factors for their development and define their association with outcomes. We studied 100 consecutive patients admitted to our general intensive care unit. We recorded relevant demographic, clinical data and maximal (max) and mean intra-abdominal pressure (IAP). We measured and defined IAH and ACS using consensus guidelines. Of our study patients, 42% (by IAPmax) and 38% (by IAPmean) had IAH. Patients with IAH had greater mean body mass index (30.4±9.6 vs 25.4±5.6 kg/m², P=0.005), Acute Physiology and Chronic Health Evaluation III score (78.2±28.5 vs 65.5±29.2, P=0.03) and central venous pressure (12.8±4.8 vs 9.2±3.5 mmHg, P <0.001), lower abdominal perfusion pressure (67.6±13.5 vs 79.3±17.3 mmHg, P <0.001) and lower filtration gradient (51.2±14.8 vs 71.6±17.7 mmHg; P <0.001). Risk factors associated with IAH were body mass index ≥30 (P <0.001), higher central venous pressure (P <0.001), presence of abdominal infection (P=0.005) and presence of sepsis on admission (P=0.035). Abdominal compartment syndrome developed in 4% of patients. IAP was not associated with an increased risk of mortality after adjusting for other confounders. We conclude that, in a general population of critically ill patients, using consensus guidelines, IAH was common and significantly associated with obesity and sepsis on admission. In a minority of patients, IAH was associated with abdominal compartment syndrome. In this cohort IAH was not associated with an increased risk of mortality.

Emergency surgery in the elderly: a retrospective observational study

M. Alcock, CR. Chilvers — Wed, 01 Feb 2012 00:00:00 GMT

We conducted a retrospective observational study in a regional hospital on patients aged 80 years or over undergoing emergency procedures. We included 202 emergency procedures performed on 178 patients over 185 separate admissions. The aim was to obtain a ‘snapshot’ of the risks of emergency surgery in the elderly and to analyse functional status both as a risk factor and as an outcome in this patient group. The most common complications were infective (21% of patients), cardiovascular (18%) and neurological (18%). Overall mortality was 9%. Increasing age, higher American Society of Anesthesiologists physical status score and poorer pre-admission functional status appeared to be associated with increased complications and mortality. Although two-thirds of both functionally independent and partially dependent patients were discharged at their original level of function, 28% of partially dependent patients required discharge to a high-level care nursing home, whereas only 5% of the initially independent patients had this poor outcome. Improvement in our ability to stratify risk in this enlarging patient group should help improve our clinical decision-making, which may have benefits both for patients and resource allocation.

Plasma free cortisol and B-type natriuretic peptide in septic shock

DJ. Sturgess, B. Venkatesh — Wed, 01 Feb 2012 00:00:00 GMT

Previous studies of patients with septic shock have independently demonstrated alterations in plasma concentrations of B-type natriuretic peptide and plasma free cortisol. Previous data suggest that a reciprocal relationship might exist. However, the relationship between these hormones in patients with septic shock is unclear. We sought to compare paired measurement of both B-type natriuretic peptide and plasma free cortisol in a study of septic shock patients. Twenty-one consecutive adult patients from a tertiary level, multidisciplinary intensive care unit underwent blood collection within 72 hours of developing septic shock. Mean±SD Acute Physiology and Chronic Health Evaluation III score was 80.1±23.8. Hospital mortality was 29%. Log plasma free cortisol demonstrated positive correlation with log B-type natriuretic peptide (r=0.55, P=0.019). Log plasma free cortisol also correlated with Acute Physiology and Chronic Health Evaluation III score (r=0.67, P <0.001) and noradrenaline dose (r=0.55, P=0.01). Acute Physiology and Chronic Health Evaluation III (P=0.001) and noradrenaline dose (P=0.02) were independent predictors of plasma free cortisol. A model incorporating both variables explained 68% of variation in plasma free cortisol (R-square=0.682). This study of patients with septic shock demonstrates a previously unappreciated positive correlation between plasma free cortisol and b-type natriuretic peptide concentration. Acute Physiology and Chronic Health Evaluation III score and noradrenaline dose were independent predictors of plasma free cortisol.

L-arginine cardioplegia reduces oxidative stress and preserves diastolic function in patients with low ejection fraction undergoing coronary artery surgery

DT. Andrews, J. Sutherland, P. Dawson, AG. Royse, C. Royse — Wed, 01 Feb 2012 00:00:00 GMT

L-arginine cardioplegia decreases biochemical markers of myocardial damage and oxidative stress in patients with normal left ventricular function. We investigated the effects of L-arginine supplemented cardioplegic arrest in patients with reduced ejection fraction. Fifty-three adult patients with left ventricular ejection fraction <35% undergoing elective coronary artery bypass surgery were randomised to receive blood cardioplegia with or without L-arginine. Following cardiopulmonary bypass, measured endpoints were cardiac troponin-I concentration at 12 and 24 hours, coronary sinus concentrations of malondialdehyde and superoxide dismutase activity at five and 15 minutes, lactic acid flux at one, five and 15 minutes and left ventricular systolic and diastolic function after protamine administration. There were no differences in cardiac troponin-I between groups. Malondialdehyde was lower in the L-arginine group, 0.28±0.12 vs 0.48±0.32 (5 minutes) and 0.31±0.14 vs 0.38±0.15 nmol.ml^-1 (15 minutes) (P=0.0004). Superoxide dismutase activity was higher in L-arginine group, 229±87 vs 191.3±68 (5 minutes), 229±54 vs 198±15 nmol.minute^-1.ml (15 minutes) (P=0.005). Lactic acid flux was lower in L-arginine group, 0.15±0.23 vs 0.48±0.32 (1 minute), 0.08±0.19 vs 0.38±0.31 (5 minutes) and -0.15±0.13 vs 0.26±0.30 mmol.l^-1 (15 minutes), (P=0.0003). There was no difference in left ventricular systolic function. The mitral annular tissue Doppler inflow (e´) velocity during early diastole improved in the L-arginine group following cardiopulmonary bypass (control 4.2±1.9 cm.s^-1 to 3.6±1.2 cm.s^-1 vs L-arginine 3.8±1.2 cm.s^-1 to 4.6±1.4 cm.s^-1) (P=0.018). In patients with reduced ejection fraction, L-arginine supplemented cardioplegic arrest did not affect postoperative cardiac troponin-I levels, but attenuated cardiac cellular peroxidation and improved early left ventricular diastolic function.

Blood loss and replacement for paediatric cranioplasty in Australia – a prospective national audit

PW. Howe, MG. Cooper — Wed, 01 Feb 2012 00:00:00 GMT

We prospectively audited blood loss and blood replacement in every child less than 24 months of age undergoing cranioplasty for craniosynostosis in Australia during 2008, in order to obtain more accurate data for the discussion of perioperative transfusion risk. A total of 127 cases were performed at seven centres. There were no directed or autologous blood donations. No patient received preoperative erythropoietin. A total of 233 units of homologous red blood cells were transfused. Overall, 83% of patients received a blood transfusion. This included 100% of patients undergoing cranial vault reconstruction (CVR) and 98% of patients undergoing fronto-orbital advancement (FOA), but only 32% of spring cranioplasty patients. Exposure to no more than one donor was achieved in 60% of FOA patients and 36% of CVR patients. Estimated blood volume loss was more than one blood volume in 36% of CVR and 36% of FOA, but only 12% of spring cranioplasty, and more than two blood volumes in 4% of CVR and 11% of FOA. Differences in surgical technique and volume of surgery between different centres appeared to affect transfusion rates. Children with recognised craniofacial syndromes and those undergoing repeat surgery appeared to have greater blood loss and blood product exposure. There were two cases of sudden massive haemorrhage secondary to dural venous sinus tear, but no death or perioperative cardiac arrest. These findings indicate that blood loss requiring blood product replacement is common in patients <24 months of age undergoing cranioplasty for craniosynostosis, particularly in patients undergoing FOA and CVR.

Comparison of haemodynamic responses following different concentrations of adrenaline with and without lignocaine for surgical field infiltration during cleft lip and cleft palate surgery in children

M. Muthukumar, VK. Arya, PJ. Mathew, RK. Sharma — Wed, 01 Feb 2012 00:00:00 GMT

Surgical field infiltration with adrenaline is common practice for quality surgical field during cleft lip and palate repair in children. Intravascular absorption of adrenaline infiltration often leads to adverse haemodynamic responses. In this prospective, double-blinded, randomised study the haemodynamic effects, quality of surgical field and postoperative analgesia following surgical field infiltration with different concentrations of adrenaline with and without lignocaine were compared in 100 American Society of Anesthesiologists physical status I children aged six months to seven years undergoing cleft lip/palate surgery. A standard anaesthesia protocol was used and they were randomised into four groups based on solution for infiltration: adrenaline 1:400,000 (group A), adrenaline 1:200,000 (group B), lignocaine + adrenaline 1:400,000 (group C) and lignocaine + adrenaline 1:200,000 (group D). Statistically significant tachycardia and hypertension occurred only in group B as compared to other groups (P <0.001). The peak changes in heart rate and mean arterial pressure following infiltration occurred at 4.3±2.4, 3.8±1.5, 5.7±3.2 and 5.9±4.9 minutes in groups A, B, C and D respectively. Surgical field was comparable among all groups. Postoperative pain scores and rescue analgesic requirements were lesser in the groups where lignocaine was added to the infiltrating solution (P <0.05). We found that 1:400000 or 1:200000 adrenaline with lignocaine 0.5 to 0.7% is most suitable for infiltration in terms of stable haemodynamics, quality of surgical field and good postoperative analgesia in children.

Incidence of difficult intubation in intensive care patients: analysis of contributing factors

Wed, 01 Feb 2012 00:00:00 GMT

Difficulties in endotracheal intubation increase morbidity and mortality in intensive care patients. We studied the problem in surgical intensive care patients with the aim of risk reduction. Patients intubated in the intensive care unit were evaluated. The intubations were performed or supervised by anaesthetists following the algorithm valid at the time of the study. Fifty percent of the 198 intubations were performed by specialist anaesthetists, 41.5% by anaesthesia trainees and 8.5% by surgical trainees. The initial attempt was by direct laryngoscopy (n=173), flexible fibrescope (n=8) or blind nasal technique (n=17). When direct laryngoscopy failed (n=7), intubation was accomplished with an intubating laryngeal mask airway (n=5), Frova stylet (n=1) or fibrescope (n=1). Thirty percent were rated as easy, 47% as moderately easy and 23% as difficult. Difficult intubations were associated with a higher incidence of anatomic anomalies, difficult bag-mask ventilation and severe oxygen desaturation. Every intubation in the ICU setting should be considered potentially difficult. The existing algorithm should be modified to incorporate the American Society of Anesthesiologists difficult airway algorithm adapted to the needs of the intensive care unit. A training program for alternative methods of airway management for difficult intubations should be established.

Improving the C-MAC video laryngoscopic view when applying cricoid pressure by allowing access of assistant to the video screen

TE. Loughnan, E. Gunasekera, TP. Tan — Wed, 01 Feb 2012 00:00:00 GMT

Cricoid pressure, as part of rapid sequence induction, may on occasion worsen laryngoscopic views and intubating conditions. We investigated whether allowing the assistant applying cricoid pressure to view the video laryngoscope screen would improve the laryngoscopic views compared to when they were blinded to the video screen. Laryngoscopy using the C-MAC video laryngoscope was performed in 51 patients undergoing elective general anaesthesia. Photographs were recorded sequentially under the following conditions: A) cricoid pressure by an assistant unable to see the video monitor, and B) cricoid pressure optimised by an assistant able to see the video monitor. These photographs were analysed offline by assessors blinded to whether the photo was obtained with blinded or non-blinded cricoid pressure application. Subjectively, 41% of views were improved when the assistant applying cricoid pressure was able to see the C-MAC screen, compared to those unable to see the screen. The view was unchanged in 45%, but initially worsened in 14%. These findings suggest that assistants applying cricoid pressure when a C-MAC is used should have access to the video image, but must also respond to requests for change from the person performing the intubation.

A useful new coma scale in acute stroke patients: FOUR score

Y. Kocak, S. Ozturk, F. Ege, AH. Ekmekci — Wed, 01 Feb 2012 00:00:00 GMT

Assessment of the severity of unconsciousness in patients with impaired consciousness, prediction of mortality and prognosis are currently the most studied subjects in intensive care. The aim of this study was to investigate the usefulness of the Full Outline of UnResponsiveness (FOUR) score in intensive care unit patients with stroke and the associations of FOUR score with the clinical outcome and with other coma scales (Glasgow [GCS] and Acute Physiology and Chronic Health Evaluation II). One hundred acute stroke patients (44 male, 56 female), who were followed in a neurology intensive care unit, were included in this prospective study. The mean age of the patients was 70.49±12.42 years. Lesion types were determined as haemorrhagic in 30 and ischaemic in 70 patients. FOUR scores on the day of admission and the first, third and 10th days of patients who died within 15 days were lower when compared to scores of patients who survived (P=0.005, P=0.000, P=0.000 and P=0.000 respectively). Receiver operating characteristic curve analysis showed significant trending with both FOUR score and GCS for prognosis; the area under curve ranged from 0.675 (95% confidence interval 0.565 to 0.786) when measurements had been made on day 3 to 0.922 (95% confidence interval 0.867 to 0.977) and 0.981 (95% confidence interval 0.947 to 1.015) for day 10. We suggest that FOUR score is a useful scale for evaluation of acute stroke patients in the intensive care unit as a homogeneous group, with respect to the outcome estimation.

End-of-life practices in a tertiary intensive care unit in Saudi Arabia

Wed, 01 Feb 2012 00:00:00 GMT

Our aim was to evaluate end-of-life practices in a tertiary intensive care unit in Saudi Arabia. A prospective observational study was conducted in the medical-surgical intensive care unit of a teaching hospital in Riyadh, Saudi Arabia. Over the course of the one-year study period, 176 patients died and 77% of these deaths were preceded by end-of-life decisions. Of these, 66% made do-not-resuscitate decisions, 30% decided to withhold life support and 4% withdrew life support. These decisions were made after a median time of four days (Q1 to Q3: 1 to 9) and at least one day before death (Q1 to Q3: 1 to 4). The patients’ families or surrogates were informed for 88% of the decisions and all decisions were documented in the patients’ medical records. Despite religious and cultural values, more than three-quarters of the patients whose deaths were preceded by end-of-life decisions gave do-not-resuscitate decisions before death. These decisions should be made early in the patients’ stay in the intensive care unit.

Ventilator versus manual hyperinflation in clearing sputum in ventilated intensive care unit patients

D. Dennis, W. Jacob, C. Budgeon — Wed, 01 Feb 2012 00:00:00 GMT

The aim of hyperinflation in the ventilated intensive care unit patient is to increase oxygenation, reverse lung collapse and clear sputum. The efficacy and consistency of manual hyperventilation is well supported in the literature, but there is limited published evidence supporting hyperventilation utilising a ventilator. Despite this, a recent survey established that almost 40% of Australian tertiary intensive care units utilise ventilator hyperinflation. The aim of this non-inferiority cross-over study was to determine whether ventilator hyperinflation was as effective as manual hyperinflation in clearing sputum from patients receiving mechanical ventilation using a prescriptive ventilator hyperinflation protocol. Forty-six patients received two randomly ordered physiotherapy treatments on the same day by the same physiotherapist. The efficacy of the hyperinflation modes was measured by sputum wet weight. Secondary measures included compliance, tidal volume, airway pressure and P_aO₂/FiO₂ ratio. There was no difference in wet weight of sputum cleared using ventilator hyperinflation or manual hyperinflation (mean 3.2 g, P=0.989). Further, no difference in compliance (P=0.823), tidal volume (P=0.219), heart rate (P=0.579), respiratory rate (P=0.929) or mean arterial pressure (P=0.593) was detected. A statistically significant difference was seen in mean airway pressure (P=0.002) between techniques. The effect of techniques on the P_aO₂/FiO₂ response ratio was dependent on time (interaction P=0.024). Physiotherapy using ventilator hyperinflation cleared a comparable amount of sputum and was as safe as manual hyperinflation. This research describes a ventilator hyperinflation protocol that will serve as a platform for continued discussion, research and development of its application in ventilated patients.

Premedication with granisetron reduces shivering during spinal anaesthesia in children

AA. Eldaba, YM. Amr — Wed, 01 Feb 2012 00:00:00 GMT

This study evaluates the effect of prophylactic granisetron on the incidence of postoperative shivering after spinal anaesthesia in children. Eighty children, American Society of Anesthesiologists physical status I to II and aged two to five years were scheduled for surgery of the lower limb under spinal anaesthesia. The children were randomised to receive 10 µg/kg granisetron diluted in 10 ml saline 0.9% intravenously (group 1, n=40) or placebo (10 ml 0.9% saline, group 2, n=40) to be given over five minutes just before spinal puncture. Shivering, core temperature and the levels of motor and sensory block were assessed. No patients shivered in group 1. However, six patients shivered in Group 2 (P=0.025). There were no significant differences in the other measured variables between the groups. Granisetron is an effective agent to prevent shivering after spinal anaesthesia in children from two to five years of age.

A new technique for post-pyloric feeding tube placement by palpation in lean critically ill patients

M. Sekino, O. Yoshitomi, T. Nakamura, T. Makita, K. Sumikawa — Wed, 01 Feb 2012 00:00:00 GMT

Various techniques have been described for blind bedside placement of a post-pyloric feeding tube. However, there is no universal method and the technique depends on the local institutional resources and expertise. The purpose of this study was to evaluate a simple new technique for the bedside placement of a post-pyloric feeding tube in an intensive care unit using palpation to confirm tube position. We studied 47 consecutive ventilated patients (mean body mass index 22.4±4.2 kg/m²) requiring enteral tube feeding for nutritional support. We monitored the maximum intensity point of injected air ‘bubbling’ by palpation and estimated tube position. We monitored the movement of the maximum intensity point from the left upper quadrant to the right upper quadrant. If the maximum intensity point on the right upper quadrant diminished or weakened, we considered the tube had proceeded beyond the pylorus. By palpation, we could feel the bubbling of the injected air in all patients, but four patients were excluded because of failure to complete the protocol. The overall success rate including the four excluded cases was 85.1% (40/47) on the first attempt and 91.5% (43/47) when we included the second attempt. The median time for 40 successful tube placements on the first attempt was 10 (7 to 23) minutes. Our new palpation technique can successfully detect the position of a feeding tube in the stomach and help guide the tube to the correct location in the post-pyloric portion of the stomach in lean critically ill patients.

Determinants of family satisfaction in the intensive care unit

K. Sundararajan, TS. Sullivan, M. Chapman — Wed, 01 Feb 2012 00:00:00 GMT

The aim of this study was to explore the degree and determinants of satisfaction of family members of patients being cared for in an Australasian intensive care unit. This was a prospective observational study that took place within a mixed medical/surgical, level three intensive care unit. One hundred and eight family members of patients staying in the intensive care for more than 48 hours were identified. Eight were excluded because next of kin contact details were unavailable. A questionnaire was posted to next of kin four weeks after intensive care unit discharge. Subjects who had not responded after four weeks were contacted by telephone and, if consent was given, a phone questionnaire was performed. Evidence of family meetings with the social worker or medical staff was sought in the patients' case notes retrospectively. Family satisfaction was measured using a 10-item questionnaire incorporating visual analogue scales. Seven subjects refused to participate. Fifty-nine responded by post and a further 25 agreed to a phone interview. Nine subjects were unable to be contacted. Eighty-four family members were included, 73 of patients who survived. Overall family satisfaction was a high 8.0 (interquartile range 6.5 to 9.5). Highest scores recorded were for communications with nursing staff (9.0), while lowest scores were for frequency of doctors' communication (7.0). Families who had meetings with the social worker or medical staff were less likely to report dissatisfaction (relative risk 0.14; confidence interval 0.03 to 0.59; P=0.08; relative risk 0.23; confidence interval 0.07 to 0.81; P=0.02). Our study found that the majority of families are happy with their care in the intensive care unit. Social work and medical meetings with the family reduce dissatisfaction.

Postoperative plasma paracetamol levels following oral or intravenous paracetamol administration: a double-blind randomised controlled trial

CN. Brett, SG. Barnett, J. Pearson — Wed, 01 Feb 2012 00:00:00 GMT

In day-case surgery paracetamol is commonly given orally preoperatively, or intravenously intraoperatively. In this double-blind randomised controlled trial we investigated which of these methods of administration achieved therapeutic plasma levels most effectively in the early postoperative period. Thirty patients undergoing day case arthroscopy of the knee were randomised to receive either 1.0 g oral paracetamol 30 to 60 minutes preoperatively (20 patients) or 1.0 g intravenous paracetamol intraoperatively (10 patients). Plasma paracetamol levels were measured 30 minutes after arrival in the recovery room. Secondary outcomes included postoperative pain scores, rescue analgesia requirements and duration of stay in the recovery room. All patients receiving the intravenous preparation had plasma levels above the analgesic level compared to less than half (7/20) in the oral group. Mean plasma paracetamol levels were 88.6 µmol/l for the intravenous group and 53.2 µmol/l for the oral group (P=0.0005). There were trends towards reduced rescue analgesia and duration of stay in the recovery room for the intravenous group although not reaching statistical significance. There was no difference in pain scores between groups. Intraoperative administration of 1.0 g of intravenous paracetamol more reliably achieved effective paracetamol levels in the early postoperative period compared to an equal dose given orally preoperatively. Only a minority of patients receiving the 1.0 g oral dose preoperatively had plasma levels in the therapeutic analgesic range.

Audit of extrapleural local anaesthetic infusion in neonates following repair of tracheo-oesophageal fistulae and oesophageal atresia via thoracotomy

Wed, 01 Feb 2012 00:00:00 GMT

In order to reduce postoperative opioid requirement, extrapleural local anaesthetic infusion dosing recommendations and guidelines for extrapleural catheter insertion were developed in our institution for ‘extubatable’ neonates requiring short-gap neonatal tracheo-oesophageal fistula/oesophageal atresia repair (via thoracotomy) and audited prospectively. Data audited included patient characteristics, analgesia details and ventilation duration. We divided patients into two groups: group 1 – term patients (≥36 weeks gestational age) with birth-weights ≥2.5 kg; group 2 – pre-term patients (<36 weeks gestational age), with birth weights <2.5 kg and those with co-morbidities. There were 26 neonates in group 1 and 11 in group 2. All received extrapleural infusions of bupivacaine or levobupivacaine: the majority (90%) ≤300 μg.kg-1.hour-1 (median duration 43 hours, range 1.5 to 72 hours); 36% required morphine infusion and 39% were ventilated (median duration 34 hours, range 3 to 140 hours). In group 1, 24% required morphine infusion compared with 64% in group 2. Most group 1 patients (77%) were extubated immediately postoperatively; 20% had short duration ventilation (median 15 hours, range 11 to 37 hours); one required longer-term ventilation (231 hours). 82% of group 2 were ventilated for a median of 72 hours (range 3 to 140 hours). Review of patients’ co-morbidities facilitated guideline revision. These now specify use in neonates requiring short-gap tracheo-oesophageal fistula/oesophageal atresia repair who are term at ≥36 weeks gestational age and ≥2.5 kg birth-weight, anticipated as ready for extubation either immediately or shortly after surgery.

Ambulatory blood pressure monitoring in an anaesthetic preadmission clinic

R. Franks, P. Macintyre, E. Dennis — Wed, 01 Feb 2012 00:00:00 GMT

When the block wears off – transitioning from regional to systemic analgesia

D. Heather, A. Cameron, J. Savage — Wed, 01 Feb 2012 00:00:00 GMT

Preparation of Datex-Ohmeda Aestiva and Aisys anaesthetic machines for use in malignant hyperthermia susceptible patients

C. Jones, N. Pollock, T. Bulger, K. Bennett — Wed, 01 Feb 2012 00:00:00 GMT

Association of single nucleotide polymorphisms with postsurgical pain level and patient-controlled analgesia consumption: evidence for the utility of Abcb1 rs1045642, Scn9a rs6746030 and Cyp3A5 rs776746 variants as predictive markers

C. Law, G. Jacobson, M. Chaddock, R. Cursons, J. Sleigh — Wed, 01 Feb 2012 00:00:00 GMT

Transthoracic echocardiography in anaesthetic pre admission clinic

P. Macintyre — Wed, 01 Feb 2012 00:00:00 GMT

Closed-loop feedback computer-controlled versus manual-controlled phenylephrine infusions for maintaining blood pressure during spinal anaesthesia for caesarean section

W. Ngan Kee, K. Khaw, Y-H. Tam, F. Ng — Wed, 01 Feb 2012 00:00:00 GMT

An overview of the anatomy of the suprascapular and axillary nerves using ultrasound and magnetic resonance imaging

D. Price, N. Kershaw, B. Clark — Wed, 01 Feb 2012 00:00:00 GMT

A randomised comparison of combined suprascapular and axillary (circumflex) nerve block with interscalene block for postoperative analgesia following arthroscopic shoulder surgery

D. Price, A. Abeysekera, M. Chaddock — Wed, 01 Feb 2012 00:00:00 GMT

A single-centre study of outcomes from fractured neck of femur – a five year audit

E. Soukhin, L. Zhou, M. Kluger — Wed, 01 Feb 2012 00:00:00 GMT

Prospective cohort study of the use of Supreme Laryngeal Mask Airway™ in 700 parturients undergoing lower segment caesarean section

WY. Yao, BL. Sng, SY. Li, Y. Lim, ATH. Sia — Wed, 01 Feb 2012 00:00:00 GMT

Correction: Adherent transversus abdominis plane catheter

G. Pattullo — Wed, 01 Feb 2012 00:00:00 GMT

Correction: Adherent transversus abdominis plane catheter – Reply

JJ. Trinca, CO. Tan — Wed, 01 Feb 2012 00:00:00 GMT

Target controlled infusion pump failure due to worn drive nut

IR. Cox — Wed, 01 Feb 2012 00:00:00 GMT

Three strikes and you’re out: unanticipated hyperkalaemic cardiac arrest following rapid sequence intubation

S. Prakash, S. Galluccio — Wed, 01 Feb 2012 00:00:00 GMT

Modification of Diamedica drawover anaesthetic equipment to facilitate introduction to an Australian teaching hospital

PM. Fenton — Wed, 01 Feb 2012 00:00:00 GMT

A heads up for ultrasound

TMA. Fernandez, C. Nixon — Wed, 01 Feb 2012 00:00:00 GMT

The use of a 1 ml syringe tube as an open reservoir during arterial cannulation

YH. Li, HL. Fu, LH. Liu, QF. Zhu, HB. Yuan — Wed, 01 Feb 2012 00:00:00 GMT

Acute renal failure and liver necrosis associated to allopurinol therapy

E. Biagioni, S. Busani, L. Rinaldi, M. Marietta, M. Girardis — Wed, 01 Feb 2012 00:00:00 GMT

Animal Models of Pain

SA. Schug — Wed, 01 Feb 2012 00:00:00 GMT

Oxford Specialist Handbooks in Anaesthesia: Neuroanaesthesia

SJ. Llewellyn — Wed, 01 Feb 2012 00:00:00 GMT

Pain Management

R. Goucke — Wed, 01 Feb 2012 00:00:00 GMT

Basics of Anesthesia. Sixth Edition

S L. Tivey — Wed, 01 Feb 2012 00:00:00 GMT

Erratum

J. Thirlwell — Wed, 01 Feb 2012 00:00:00 GMT